Inside HRSA, October 2008, Health Resources and Services Administration
 
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HRSA Urges Grantees to "Screen & Intervene"

Amid increasing evidence that far more Americans than previously thought have potentially addictive alcohol and drug use patterns, a broad front of federal agencies are set to launch a nationwide campaign to encourage universal substance abuse screening.

Spearheaded by the White House Office of National Drug Control Policy (ONDCP), the “Screening and Brief Intervention” (SBI) initiative builds on the work of SAMHSA and harnesses the combined assets of such agencies as the National Highway Traffic Safety Administration, the Veterans Administration, CDC, and NIH, along with private health insurers and medical associations.

With 1,110 health center grantees and 16 million patients under care at more than 7,300 health care sites nationwide — and more than 530,000 clients in the Ryan White HIV/AIDS program — HRSA is expected to play a pivotal role in the effort.

Steve Smith, senior advisor to HRSA Administrator Elizabeth Duke, spoke at a White House summit on the initiative Sept. 5.

“Screening of this kind already is going on in a lot of the health centers, in one form or another,” Smith said. “But it’s now a big part of government efforts at every level to improve mental health services — because substance abuse is implicated in so much of what we see going wrong in peoples’ lives.”

 

HRSA Senior Advisor Steve Smith
HRSA Senior Advisor Steve Smith addressed the White House SBI Summit.

 

The protocol would have clinicians routinely ask their patients a concise series of questions about their consumption patterns, followed immediately by one or more counseling sessions for those who are deemed at risk.

The procedure is premised on research findings that many chronic drinkers and drug users are still capable of altering their behavior if they are alerted to the potential health consequences in time.

For men, the threshold question is whether they regularly drink three or more alcoholic beverages in a day — or more than 14 in a week. For women, it’s two drinks per day, or more than 11 weekly. Those who answer yes are considered candidates for intervention.

In January, Medicare and Medicaid agreed to start reimbursing physicians for administering the short screening questionnaire to their patients. Three months later, the Federal Employees Health Benefits Program followed suit, providing SBI for 5.6 million government workers.

Dr. Westley Clark
Dr. Westley Clark of SAMHSA spoke to Ryan White HIV/ AIDS grantees in August.

Dr. Ruth Finkelstein
Dr. Ruth Finkelstein at the Ryan White meeting.

  

A recent survey by the American Psychiatric Association found that 58 percent of private insurance carriers now reimburse for the screening/ counseling services — based on evidence that these relatively inexpensive “interventions” are enough to convince up to a third of heavy drinkers to cut back or quit before they become full-blown alcoholics.

One car ride away from disaster

The White House SBI initiative had its genesis in 2006 with the appointment by President Bush of Dr. Bertha Madras as deputy director for demand reduction in ONDCP. A former professor of psychobiology at Harvard Medical School, Madras had performed research on substance abuse and how it gradually alters brain chemistry in ways so subtle that many users are unaware they are slipping toward dependency.

“Twenty-one million Americans are out there walking around with serious substance problems that even they don’t recognize,” Madras told an audience of HRSA grantees at the HIV/AIDS conference in August. “But they’re one car ride away from a major accident, or one family conflict from abusing their spouse or child.”

Or one moment of impaired judgement . . .

“Intoxication,” Madras said, “is strongly associated with behavior that places people at significantly greater risk of acquiring HIV and other STDs.”

By 2005, research had established that as much as a third of all emergency room patients — and half of those admitted for severe trauma — fit the profile of “problem” or “high-risk” drinkers.

Among adolescents, overall drug use is down, but one out of four high school students say they drink heavily on occasion. That number rises sharply once students enter college, where as many as two in five engage in regular “binge drinking.”

  

In a 2005 survey by the CDC, almost a quarter of sexually active young adults, aged 15-24, reported having unprotected sex while under the influence.

“They’re doing things that sometimes they can’t even remember the next morning,” Dr. H. Westley Clark, director of SAMHSA’s Center for Substance Abuse Treatment, told the Ryan White grantees, “and probably the last thing they ever thought about the night before was using a condom.”

The ground-level view

New evidence emerging from an ongoing special project funded by HRSA in seven U.S. cities suggests that chronic “self medication” is a driving force behind the spread of HIV/AIDS in medically underserved inner-city neighborhoods.

Beau Mitts of the Houston Department of Health and Human Services, a HRSA grantee, explained in a seminar at the conference that substance abuse is so pervasive that it often leads his young clients to delay or drop out of treatment.

“Just about all of them are using something when they first present,” Mitts said. “It takes an average of four contacts before a kid agrees to enter into care” after first being notified of a positive test result, “and substance abuse is one big reason.”

Of the 200 young males in the research group nationally, 62 percent reported that they had consumed alcohol in the preceding two weeks. And that’s not all they’re doing.

“Way more than half (68 percent) are using marijuana or hashish when they first come through the door,” reported Dr. Julia Hidalgo, who runs the technical evaluation center for the project at George Washington University. “Retaining them in treatment is a monumental struggle.”

And failing to retain them creates ideal conditions for further mutations and transmission of the virus, noted Dr. Ruth Finkelstein, a leading researcher in both HIV/ AIDS and substance abuse treatment at The New York Academy of Medicine.

“There is no room for partial adherence when you’re taking these anti-retroviral drugs,” she noted.

Underscoring the need for better screening, Hidalgo observed that “36 percent of these kids managed to get through an ER in the preceding 90 days without being identified” as either HIV positive or at-risk due to substance abuse.

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